Elsevier

The Breast

Volume 24, Issue 3, June 2015, Pages 230-236
The Breast

Original article
RTOG, CTCAE and WHO criteria for acute radiation dermatitis correlate with cutaneous blood flow measurements

https://doi.org/10.1016/j.breast.2015.01.008Get rights and content

Abstract

Background

Various clinician-assessed scoring criteria have been used to grade acute radiation dermatitis. However, it is not known whether these scoring criteria correlate with changes in objective skin biophysical parameters and patient-reported symptoms following radiotherapy. We seek to correlate three different clinician-assessed scoring criteria with skin biophysical changes and patient-reported symptoms in breast cancer patients undergoing radiotherapy.

Methods

A prospective cohort study was performed in a university hospital medical center. The severity of acute radiation dermatitis in 101 breast cancer patients was graded using the RTOG, CTCAE and WHO clinical scoring criteria. We also measured various skin biophysical parameters (skin blood flow, pigmentation, hydration, and pH) by non-invasive techniques before and after radiotherapy. Patient-reported breast symptoms (pain, itching, local heat, and tightness) were evaluated using a questionnaire.

Results

The three different clinician-assessed scoring criteria correlated most strongly with changes in cutaneous blood flow following radiotherapy for breast cancer (correlation coefficient 0.70 for RTOG, 0.68 for CTCAE, and 0.50 for WHO). All three scoring criteria also showed moderate correlation with changes in skin pigmentation (correlation coefficients 0.4–0.5), but showed no significant correlation with skin hydration or pH (correlation coefficients <0.2). The scoring criteria correlated poorly with patient-reported breast symptoms (correlation coefficients <0.3).

Conclusions

The three clinician-assessed scoring criteria (especially the RTOG and CTCAE criteria) show strong correlation with cutaneous blood flow measurements, but correlate less well with other skin biophysical parameters and patient-reported symptoms.

Introduction

Acute radiation dermatitis is a frequent adverse effect in patients undergoing radiotherapy for breast cancer, and its severity ranges from faint erythema and dry desquamation of the skin to moist desquamation and ulceration [1], [2]. Radiation-induced skin injury may impair a patient's physical functioning and quality of life [3]. It may also result in interruption or cessation of radiotherapy, which may have a negative impact on cancer treatment [4], [5].

Traditionally, the severity of acute radiation dermatitis is often assessed and graded subjectively by the clinician using various clinical scoring criteria. The most commonly used clinician-assessed scoring criteria are the Radiation Therapy Oncology Group (RTOG) [6], [7], [8], [9], the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) [10], [11], and the World Health Organization (WHO) criteria [12], [13], [14] (Table 1). The RTOG criteria had been regarded as one of the most clinically useful criteria for the evaluation of acute radiation dermatitis [6], [7], [8], [9]. However, one drawback of the original RTOG criteria is that bright erythema and patchy moist desquamation are both graded as 2, although these skin changes may not be regarded as equal in severity from the patients' perspective. The RTOG scoring criteria was modified in some studies, and grade 2 in the original criteria was further subdivided so that ‘tender or bright erythema’ was graded as 2 and ‘patchy moist desquamation’ was graded as 2.5, since a broken skin was regarded to be more severe than erythema [8], [14]. In this study, both the original and modified versions of the RTOG criteria are used.

Some limitations of these clinician-assessed scoring criteria are that they are not objective, and do not provide a quantitative measure of a specific clinical or physiological parameter. In recent years, a number of ‘objective’ techniques for the evaluation of acute radiation dermatitis have been described. These include reflectance spectrophotometry or colorimetry for the measurement of skin erythema [15], [16], [17], [18], [19], laser Doppler flowmetry for the measurement of cutaneous blood flow [20], [21], [22], [23], [24], and measurement of skin hydration using a dielectric method [25], [26].

An additional limitation of clinician-assessed scoring criteria is that they only evaluate the appearance of radiation-damaged skin from the clinician's point of view. They do not measure how radiation treatment affects the way a patient feels. To address this issue, various questionnaires have been developed to assess patient-reported symptoms from the patient's perspective, without interpretation or modification by a clinician [27].

Currently, it is not known whether commonly used clinician-assessed scoring criteria for acute radiation dermatitis correlate well with objective skin biophysical parameters and patient-reported symptoms. In this study, we seek to correlate three different clinician-assessed scoring criteria (original and modified RTOG, CTCAE and WHO) with changes in skin biophysical parameters (including skin blood flow, pigmentation, hydration, pH) and patient-reported symptoms (pain, itching, local heat, tightness) in breast cancer patients undergoing radiotherapy.

Section snippets

Recruitment of patients

This is a prospective cohort study performed at a university hospital medical center. Female patients with newly diagnosed unilateral breast cancer at Kaohsiung Medical University Hospital were enrolled from August 2012 to July 2013. All patients received breast conserving surgery followed by postoperative radiation therapy. The exclusion criteria for this study were age >70 years, patients with distant metastasis from breast cancer, recurrent breast cancer, patients who received simple or

Clinical features of patients

A total of 107 women who received postoperative radiation therapy for breast cancer were enrolled in this prospective study. Subsequently, 6 patients withdrew from the study leaving 101 patients available for analysis. Clinical characteristics including age, breast cancer stage (determined according to the American Joint Committee on Cancer staging manual 7th edition), frequency of various comorbidities (diabetes mellitus, hypertension) and different treatments for breast cancer (previous

Discussion

Acute radiation dermatitis is commonly seen in breast cancer patients receiving radiotherapy, and occurs within hours to weeks after initiation of radiation treatment. Clinically, patients with acute radiation dermatitis may present with skin erythema, edema, dry desquamation, moist desquamation, and changes in pigmentation. Severe forms of radiation dermatitis may present with skin ulceration, hemorrhage and necrosis [2].

The severity of acute skin reactions following radiotherapy can be

Conflict of interest statement

None declared.

Funding sources

This work was supported by grants from the National Science Council (100-2622-B-002-001-CC2QC094002), the Ministry of Health and Welfare (contract no. MOHW103-TD-B-111-05), and Kaohsiung Medical University Hospital (grant number KMUH102-2M45, KMUH103-3T02), Taiwan. The funding sources had no role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.

Acknowledgments

The authors would like to thank Professor Yi-Hsin Yang and Dr Ming-Yen Lin (Statistical Analysis Laboratory, Department of Medical Research, Kaohsiung Medical University Hospital) for assistance with statistical analysis.

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